Postings from Emily's Kennedy School adventure

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My job in Massachusetts’ Executive Office of Health and Human services has been to manage the implementation of a Court-ordered judgment in a class action lawsuit against Massachusetts’ Medicaid program. Since 2007, we have been implementing the four phases of the judgment, including a statewide system of six new children’s mental health service, serving approximately 25,000 youth and their families per year. In addition to overseeing implementation of the judgment, my job is to meet regularly with the Court-appointed monitor, who serves as the Judge’s “eyes and ears,” and to regularly report to the Court and attend Status Conferences with the Judge and the parties. We have implemented everything in the judgment and the Federal Judge in the case, Michael Ponsor, is in the process of evaluating how much longer he thinks the Court should directly oversee the State’s management of the new system. Fundamentally, it comes down to his confidence in the State’s ability and commitment to closely monitor the quality of the services, and to work with the contracted human service provider agencies to continually improve the quality of services.

We face three big challenges. The first is that the field of children’s mental health is still developing. We have more and better interventions than even ten years ago, but the symptoms and conditions that fall under the umbrella of “children’s mental health” are very varied and complex. There is no one consensus theoretical or treatment model, but a range of models and treatments, each variously endorsed by the range of professionals who treat children with mental health conditions: primary care physicians, psychiatrists, psychologists, clinical social workers, educational psychologists, neurologists, mental health counselors, clinical nurse specialists.

The second challenge is that the private provider agencies that contract with the State to deliver mental health services are primarily staffed by young clinicians a few years out of their clinical training programs. Their supervisors are clinicians with more experience, but changes to how such programs are funded, by a variety of government agencies, have made it harder for programs to provide as much supervision as they used to.

The third challenge is that we do not have good tools, at all, to measure the impact of services on the children who receive them. These are children on Medicaid, so, with few exceptions, they are poor. The data we do have show that many of these children face terrible losses: a father who goes to prison, a brother murdered, a beloved grandparent who dies. They also faces the stresses and strains of poverty…food insecurity, housing insecurity, etc. These life events often have more of an impact on the child’s well-being, than even the highest quality mental health service.

To meet these challenges we use a couple of strategies that could be enhanced by technology: we pay for various trainings for provider agency staff; we have sporadically gathered sub-groups of clinicians together to share “lessons learned” with their colleagues across the state; and we have used a couple of different strategies to collect feedback from the parents of children receiving the services. For the project, I may need to focus just on methods to support learning across the provider agency staff, but if I can spend some time researching methods of gathering family input, I will.

So the goal, for the provider staff, is to identify technologies, processes and venues, virtual and real, to support shared learning across hundreds and thousands of staff who are working with children and their families in the six new services. There are many sub-groups: staff who provide emergency mental health crisis intervention; staff who deliver a comprehensive team-based process, with families, called “Wraparound”; staff who primarily work with adolescents; staff who work with little kids, etc. My goal is to identify a number of different communication strategies that might be helpful and to also think about whether a particular strategy should be provided by the State, or owned by the community of practitioners.

I plan to interview Nicco Mele, as well as classmates involved in other kinds of work in which there are “communities of practice” (classmates in development and the military, for example) for ideas and leads to pursue. The product will include a conceptual framework for children’s mental health communities of practice, a set of recommended technologies and approaches to support communities of practice and a plan for engaging interested practitioners to implement appropriate strategies.

The primary reason I have been a late adopter of various online technologies is that digital culture has been really unappealing to me. It has seemed overly rational/technical/intellectual, i.e. not the product of people who embody a balance between heart and mind. It also has seemed self-regarding with an ahistorical and acultural perspective. In Nicco Mele’s presentation during the Harvard Kennedy School’s summer program, he talked about the opportunities and threats of digital culture in a way that made sense to me and I realized his course Media, Politics and Power in the Digital Age could serve as a bridge for me into this culture.

In the course I’ve loved reading the many thoughtful commentators and analysts of the digital world. It was helpful to read Clay Shirky early on because he describes so clearly what digital technology does: make group- and network-forming easy, cheap and fast; make publishing easy, cheap and fast; blur “professional” and “personal” content. These are the features that Ethan Zuckerman and Zeynep Tufekci reference as they analyze the role of digital media in the Arab Spring in this week’s readings.

These readings were terrific because they concern the operation of digital media in real, messy, human life, not theories of digital media functioning. The articles and talks (other than Morozov’s Afterward) carefully analyze the role of digital media in Tunisia and Egypt and describe a pattern we’ve seen before: digital media playing critical roles in a complex ecology of various forms of media and communication, in the context of a political process with historical roots and present conditions and precipitants. This echoes the insights of Dean Starkman and Peter Dauo who describe complex interactions between digital media, broadcast media and political processes.[1]

However, it wasn’t until I read Morozov’s Afterward[2] and Lanier’s article “The Hazards of Nerd Supremacy”[3] that I understood why I liked the Arab Spring readings so much. Tufekci and Zuckerman, as scholars analyzing the use of digital media in the Arab Spring, came to the task seemingly free of the ideologies criticized by both Evgeny Morozov (internet centrism) and Jaron Lanier (digital ideology). They both exhibit what Morozov describes as “cyber-realism” and “cyber-agnosticism”: “…cyber-realism helps us to perceive Internet technologies as they are situated in the socio-technological world, while cyber-agnosticism helps us to evaluate, augment, or ﬁght them, free from any ideological biases.”[4] They both seem ready to “see what’s there” and understand the complexity of the phenomena they study. Their descriptions and analyses add to our understanding of the role of digital media in the Arab Spring.

I loved Jaron Lanier’s Atlantic article “The Hazards of Nerd Supremacy: The Case of WikiLeaks.” I related to his perspective on the “nerd” community, I think as a fellow middle-aged person. By the time you’ve lived 45+ years, you’ve seen enough of life to know just how common it is for us humans to seize on a new and exciting thing, invest tremendous hope in it, grossly overestimate its unique power and promise, and allow it to take up too much of our vision and perspective. We recognize this pattern because we’ve done it several times already and we’ve lived to see that most things aren’t as fantastic or terrible as we thought they were. I appreciate his cautionary tale about the formation of the Electronic Frontier Foundation and the “surge of ego” that he thinks fueled its early work. He concludes the story with the disarmingly simple and profoundly true statement: “When you feel that urge to power within yourself – that is when you should be most careful.”[5]

Lanier is a revelation to me, as he is someone deeply embedded in “nerd” culture, yet with profound concerns with personhood and “the shared project of having a civilization.”[6] His commentary deepens the sense of familiarity and recognition I experienced listening to Nicco Mele’s lecture this summer. Lanier’s article performs a service for those of us outside nerd culture, to articulate, in terms we can understand, the critical questions we all face in setting values and norms within the digital community. Consequential issues are now being debated about intellectual property, privacy and security. The millions of us who use digital media, but aren’t part of the digital elite, have to step up to both understand what’s at stake and to work with others to define and fight for standards that will protect individual freedom and democratic societies and governments.

My jaw dropped when I read in Sasha Issenberg’s story “A More Perfect Union” that the Obama re-election campaign started its work “confident it knew the name of every one of the 69,456,897 Americans whose votes had put him in the White House.”[1] The article explains that while, of course, the ballot had been secret, Obama’s data analysts could look at lists of voters by precinct and be pretty sure they knew who had voted for him.

All of the readings for this week describe various campaigns’ use of YouTube, email, social media and data analytics in the 2008 and 2012 presidential primaries and general elections, as well as Sen. Harry Reid’s 2010 re-election campaign. The “gist” of it is this: campaigns now have the capacity to target communications and online and offline relationship management activities to individual voters. Several factors make this possible: 1) the vast array of information available on all of us, for a price, from commercial data warehouses; 2) the development of huge and sophisticated databases to collect data on voters, including, as the Obama campaign did, 1000 data elements per voter; 3) the ability to learn, through constant randomized experiments, the best way to communicate a certain message to a certain constituency. Issenberg’s story references a couple of interesting examples from the Obama campaign that demonstrated how the reality of which voters were persuadable on which issues defied conventional campaign wisdom.

The ability to communicate with voters, individually and almost in real-time, and to keep learning from these interactions, has tremendous potential to improve our democracy. These tools give us the means to learn much more about people’s real concerns, instead of losing so much “signal” in the “noise” of polls based on samples. And the tools give us the ability to help people come together around shared concerns.

But, I think these tools pose risks to our democracy as well. In his book The MoveOn Effect, David Karpf writes: “A/B testing within advocacy organizations moves them further away from the passive and moderate American voter. In the tradeoff between political participation and public deliberation, MoveOn’s engagement repertoire is weighted toward improving participation.”[2] I think it is reasonable to assume that the A/B testing within political campaigns carries a similar risk. I worry that the very technology we use reinforces simplistic thinking and crowds out public deliberation.

I’m more concerned about these dynamics in presidential campaigns than congressional or state and local campaigns. These tools are a fantastic way for candidates and elected officials to have more frequent, higher quality and two-way communication with constituents. The fact that this dramatically new style of campaign, with all the ways it felt so different – more intimate, more collaborative, so evocative, happened in the presidential campaign invited the American people to invest all our hope, all our tremendous longing on…one man. He was doomed to disappoint…and it was the wrong message for our country.

In Dean Williams’ class on leadership I am learning a model of leadership that makes great sense to me. In it, leadership is defined as mobilizing organizations, communities and nations to face reality and “change values, habits, practices, and priorities in order to deal with the real threat or the real opportunity that the people face.”[3] There are many things this definition of leadership calls for in a presidential candidate, or President. One of them is for the President to tell the truth about our government – as designed by the founders, power is divided. The Presidency is important, but so is Congress. The people have to use their power, not just to elect a President, but to elect their Representative and Senators. President Obama’s work to empower and engage voters was important and ground-breaking, but he needed to help broaden the people’s understanding of what they can, and must, do.

I also know that what I am writing is “ridiculous”. People don’t want to hear about divided government and the fact they need to do more than the back-breaking work of electing a President. I don’t honestly know if anyone can get elected President in the United States, at this time in history, without drawing on the powerful and false illusion of the Presidency’s power.

This is a great set of articles: Clay Shirkey’s wake up call to newspapers in his 2009 blog post “Newspapers and Thinking the Unthinkable”[1], Dean Starkman’s muscular challenge to Shirkey, Jarvis and Rosen in the Columbia Journalism Review “Confidence Game”[2] and Daou’s important insights into the interdependence of the media, political establishment and the “netroots” in the online article “The Triangle: Limits of Blog Power”[3].

Shirky describes very powerfully the difficulty newspapers have had in comprehending the “unthinkable” potential implications of the internet for newspapers. He makes good use of Elizabeth Eisenstein’s research into the experience of change after the development of the printing press, using it to illustrate the scope and disruptiveness of the changes currently underway as a result of the digital revolution. As Starkman writes in his article, Shirky “has brought to the newspaper industry, if nothing else, is a salutatory sense of urgency. Essentially: wake the f*ck up.”(pg. 5)

While agreeing with much of Shirky’s analysis, Starkman strongly defends three things: 1) the importance of journalism in a democracy, 2) the value of journalism’s ethics and craft and 3) the need for journalists to have institutional back-up in order to hold powerful individuals, businesses and institutions accountable. He takes comfort in recent improvements in the bottom line for the New York Times and the Wall Street Journal and believes there is public support for public-interest reporting. In addition to making his argument about the continuing value and viability (in some form) of public-interest journalism, he makes this critically important observation about The Guardian’s investigation of the phone hacking scandal involve Rupert Murdoch’s News Corp.: “…traditional investigative reporting broke the story, while social media propelled it to the stratosphere – heights the paper never could have achieved on its own. More than 150,000 people used social media, for instance, to register opposition to News Corp.’s takeover of bSkyb, which was soon scuttled.”(pg. 13)

This point echoes Daou’s observations from his work on John Kerry’s 2004 Presidential campaign: “Looking at the political landscape, one proposition seems unambiguous: blog power on both the right and the left is a function of the relationship of the netroots to the media and the political establishment. Forming a triangle of blogs, media and the political establishment is an essential step in creating the kind of sea change we’ve seen in the aftermath of Hurricane Katrina.” He goes on to describe more specifically how this worked in the case of Hurricane Katrina: “…outspoken left-leaning bloggers are joined by leading Democrats and reporters who have no choice but to describe the catastrophic results of Bush’s dismal leadership.” (pg. 2)

As someone who’s worked in government for a long time, I’ve watched with trepidation as the Boston Globe has shrunk in size, scope of coverage and staff. I know how critical journalism is to the political process, as it holds power accountable and brings needed attention to various problems and issues. However, during this same time, I’ve also watched Public Radio grow by leaps and bounds, evidence of a sizable community willing to pay to support high-quality public interest journalism.

I see reason for hope in the themes in these articles. I appreciate Shirkey’s enthusiasm for the potential of peer-production. I’ve read/seen/listened to media coverage of hundreds of issues of which I had direct knowledge. The reporting almost never got it quite right…particularly when it came to reporting on internal political dynamics. I can imagine networks improving sources for reporters and peer production offering a much richer understanding of the issue/phenomenon. However, I also appreciate Starkman’s defense of public interest journalism, particularly that it takes resources, time, expertise and institutional support. The hopeful common ground I can see is that I think Shirky, Rosen and Starkman (and others who think like them) could agree that what is needed, in addition to peer production, is good journalism, if not newspapers.

I like Starkman’s description of good journalism: “In journalism, real authority starts with reporting. Knowing your stuff, mastering your beat, being right on the facts, digging under the surface of things, calling around to find out what happened, verifying what you heard.”

The idea that there are powerful synergies between peer-production, networks and journalists, explored by both Starkman and Daou, frankly makes more sense to me than some of the more absolutist visions of some netizens. And, while it may very well be that the forms that emerge and coalesce over the next 20, 30 or 40 years would be unrecognizable to us today, I think it will unfold, not without pain, but in a process of creation, experimentation, failure and success that we can recognize as life.

I use Wikipedia a lot, mostly to learn about new things, either something I come across that I don’t know about, or to simply to satisfy my curiosity about something. I love the breadth and depth of Wikipedia. However, I had never looked up an article about my work. For this assignment I looked up the Wikipedia article about Massachusetts’ Health Care Reform legislation, enacted in 2006 and forming the basis of “Obamacare”. This is a subject I know well, because I served as Research Director for the Massachusetts’ Legislature’s Committee on Health Care Financing during the time the Committee drafted and staffed the bill, through the Committee process, the floor debate in the House, the House/Senate conference committee and the Legislature’s overrides of Governor Romney’s vetoes.

The 2006 Health Care Reform legislation, Chapter 58 of the Acts of 2006, is a very complex market-based approach to increasing access to health care insurance. The explicit goal, among the many stakeholders and advocates for this law, was to do something about access. We thought it would have benefits for efficiency, but it was not intended to reform the delivery or cost of health care.

The best way to think of it, and the way we always talked about it, was as a “three legged stool” in which “everyone played their part”: employers, by providing health insurance as a benefit; the state, by subsidizing insurance for people who didn’t have employer-sponsored insurance and couldn’t afford it, and individuals, by buying health insurance. We built on a strong base of employer-sponsored insurance in Massachusetts, as well as a Medicaid program that had been creative about using federal waiver authority to expand coverage. To create the three-legged stool we needed to: 1) create an easy-to-use online insurance market, called the Health Connector; 2) restructure the market by combining the small group and individual policy markets; 3) shift money from the free care pool, that partially reimbursed hospitals for charity care, into insurance subsidies for low-income residents; 4) create some sort of requirement on business, to prevent the “free rider” effect; and 5) require individuals to obtain health insurance or face a penalty.

The Wikipedia article for “Massachusetts health care reform” has several paragraphs of good, clear, factual content, written by the staff of the Health Connector. Overall, however, the article is of poor quality, in sections very difficult to understand, containing inaccuracies, variable neutrality, and significant omissions. It lacks an overarching narrative framework to give a “big picture” of the law’s provisions, a framework that would make it easier to understand the relationship between the law’s various provisions. It also uses health care policy jargon in places, without sufficient explanation. Finally, one of the most notable things about the Health Care Reform law is the extensive coalition of parties supporting it, from business, to political leaders, key civil society players and grass-roots political organizing, particularly through faith communities. A few highlights of this story are included, but it fails to convey the remarkable social convergence that brought about passage of this significant piece of legislation. The article also needs more information about the insurance subsidies for low-income people, and the expanded Medicaid coverage.

The citations generally look quite good, but much of the data on the performance of the law is out of date, mostly from 2010. Keeping the article up to date, as the program continues to operate and generate performance data, will be an ongoing need.

The readings of the past two weeks have given us a look “under the hood” of the Internet: why is it so powerful and what does it enable us to do? How does it operate, by whom is it governed? The readings help us understand the changes we are experiencing, while also warning us of downside risks to these technologies and the need to develop democratic governance of this truly global resource.[1]

As we learned from Clay Shirky in Here Comes Everybody, the Internet has unleashed unprecedented group forming by people all over the world because the cost, in terms of money and of effort, has simply collapsed.[2] The recent readings explore the nature of networks and their benefits. Howard Rheingold, in Net Smart, recounts the research that led to the discovery of “small world networks”, specifically, that people are, on average, six people away from any other person in the world.[3] He also references Mark Granovetter’s research finding that “weak ties”, people we know, but who are not family or close friends (“strong ties”) can be important sources of information and new perspectives, precisely because they are outside our more homogeneous “strong ties” circle.[4]

In Connected, Christakis and Fowler write that the Internet is making new social forms possible and that these new forms are radically different in four ways:

Enormity: a vast increase in the scale of our networks

Communality: we can share information and contribute to collective efforts on a much broader scale

Rheingold asked Marc Smith, PhD., an expert in social network analysis, why people would give their time and attention to people they didn’t know online. Marc replied, very succinctly: “Social capital, knowledge capital and communion.”[6]

We can be grateful to the community of engineers and scientists who created the Internet and the World Wide Web. Rebecca MacKinnon, in Consent of the Networked, quotes Harvard law professor Yochai Benkler who describes the Internet as both the product and incubator of “commons-based information production, of individuals and loose associations producing information in non-proprietary forms.”[7] She goes on to describe the digital commons as “as vast and growing universe of engineering inventions, software, and digital media content, created by people who have chosen to share their creations freely, because the material barriers to and costs of organizing have dropped dramatically.” [8]

The private sector is also responsible for the power of the Internet. Larry Page of Google started with the idea that “the entire Web was loosely based on the premise of citation and annotations” but that you couldn’t trace links backwards. Starting out simply to solve this problem, he landed on an extremely powerful principle for search, that the value of a website could be measured by the number of links to it and the degree to which the linking sites were further linked. This created a truly meritocratic and living ecology for web content that has created tremendous value for web users everywhere.[9]

When we humans develop or discover a new thing, whether it’s an idea, philosophy or technology, we can’t help but be excited about its potential. It does seem, though, that we repeatedly over-estimate the power and reach of the new thing. It’s as if we attach our deep yearning for freedom, fairness, safety, prosperity onto new developments that seem to have the potential to carry that much change. We’ve done this with the Internet, hoping that the technology, in and of itself, would somehow permanently change power relationships in the world. But there is nothing surprising about the fact that people are using the Internet to further their own priorities and interests, whether that be making money, making revolution or holding on to state power.

I understand the exhilaration felt by Tech Utopians – these technologies give us instant access to the world’s knowledge and instant access to the world’s people. But, exhilaration can lead you to believe that everyone else sees the same potential that you do…which can lead you to neglect the essential work of developing political support to protect and institutionalize the new transformative innovation.

Rebecca MacKinnon, thankfully, gives us a clear-eyed view of the threats to the digital commons from authoritarian governments and from the private enterprises who own the Internet infrastructure. More importantly, she also articulates a plan of action to protect the Internet’s essential qualities and bring it under democratic governance.

In his book Here Comes Everybody, Clay Shirky tells the story of the collapse of the cost of group formation and communications. Social media has removed the barriers of geography and of simply knowing about each other. According to Shirkey, institutions have always had the monopoly on organizing people because, as we know, organizing even a small group of people to achieve a task takes effort. Social media has reduced the cost of organizing below the cost of maintaining an organization, meaning that these activities can no longer be performed by institutions. However, Shirkey says, this has produced a new category: “serious, complex work, taken on without institutional direction.” (Pg. 47)

Shirkey goes on to describe how, as a result of the collapse of the cost of communication, “personal communication and publishing, previously separate functions, now shade into one another. One result is to break the older pattern of professional filtering of the good from the mediocre before publication; now such filtering is increasingly social, and happens after the fact.” (pg. 59) He describes this as mass amateurization of journalism and publishing and notes: “The pattern here is simple – what seems like a fixed and abiding category like ‘journalist’ turns out to be tied to an accidental scarcity created by the expense of publishing apparatus.” (Pg. 76) The “restructuring” of the media business is not limited to those businesses, since, in Shirky’s words, “…whatever else they do, all businesses rely on the managing of information for two audiences – employees and the world.” (Pg. 107)

New tools for communication make something else possible – they allow people to participate with others online at very different levels of involvement. In the offline world, varying levels of participation in a group creates tension, while online forums make it easy for thousands of people to participate in small ways. This is another example of the “long tail”: many people can contribute a little effort and that adds up to a substantial amount. (These patterns of involvement are also described by a Power Law distribution.)

The result can be extremely powerful, as demonstrated by Linux and Wikipedia. Shirkey offers insight into the dynamics at play here, that an open source ecosystem reduces the cost of failure, allowing for what he calls “distributed exploration”. He asserts that “The only way to uncover and promote the rare successes is to rely, yet again, on social structure supported by social tools.” (Pg. 233)

He ends the book with an interesting model for using social tools, saying they are the result of a “successful fusion of a plausible promise, an effective tool and an acceptable bargain with the users.” (Pg. 261). The promise is what makes a person decide to join the group. They must see some value in it. He then describes a way of thinking about “goodness of fit” between tools and the purposes of the group. He describes the bargain as the most complex part of the model, “in part because it is the least explicit aspect and in part because it is the one the users have the biggest hand in creating, which means it can’t be completely determined in advance.” (Pg. 270)

Tim O’Reilly’s article What is Web 2.0 describes design characteristics of the emerging “next generation” web…characteristics that support the patterns so clearly illustrated by Shirky. The fundamental shift in Web 2.0 is the conceptual and actual shift from the desktop to the web…and from software and hardware companies to companies providing services through the web. Of the eight Web 2.0 Design Patterns O’Reilly describes, perhaps the most telling is “Data is the next Intel Inside”. This means that at the heart of the value of Web 2.0 is data, generated by users, collected in specialized databases by web-based companies. This data allows companies to reach out to the entire web, to the “long tail” and not just the “head.” It also allows companies to continually improve and to co-create value with their users.

For a short, clear discussion of Web 2.0, see this blog post by Tim O’Reilly

Shirky’s analysis of how social media is changing behavior is incredibly helpful and his analogies are very effective. I think his prediction that journalism will become entirely amateurized may be simplistic. It depends on whether the collective wisdom of the crowd will function as an effective curator (identifying good content and assessing journalistic quality) or whether society will seek other specialized expertise.